NUR.213 - Ch. 46 Renal & Dialysis
The nurse is preparing to perform peritoneal dialysis for a patient with chronic kidney disease. Which osmotic agent will the nurse obtain for the dialysis exchanges? Dextrose Normal saline Icodextrin solution Amino acid solution
Dextrose Rationale Dextrose is the most commonly used osmotic agent used in peritoneal dialysis. Normal saline solution is not used in peritoneal dialysis. Icodextrin and amino acid solutions are used as alternatives to dextrose.
The registered nurse is teaching a student nurse about the preoperative care to be provided to a patient before kidney transplantation. Which statement made by the student nurse indicates effective learning? "I should label the access site as 'Dialysis access, no procedures.'" "I should not explain the need of immunosuppressant drugs before surgery." "I should inform the patient that dialysis is not required after transplantation." "I should not empty the peritoneal cavity of patients undergoing peritoneal dialysis."
"I should label the access site as 'Dialysis access, no procedures.'" Rationale In order to prevent the use of the extremity to draw blood for infusions and to conduct blood pressure measurements, the nurse should label the vascular access site with a note that says "Dialysis access, no procedures." Patients should take immunosuppressant drugs to prevent organ rejection after organ transplantation. Patients need to undergo dialysis even after kidney transplantation because the kidney will not work for a few days or weeks. The nurse should ensure that the peritoneal cavity is emptied before transplantation. p. 1095
Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse? A 50-year-old white female with hypertension A 61-year-old Native American male with diabetes A 40-year-old Hispanic female with cardiovascular disease A 28-year-old African American female with a urinary tract infection
A 61-year-old Native American male with diabetes Rationale It is especially important that the nurse should teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD six times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. African Americans have the highest rate of CKD because hypertension is increased significantly in African Americans. A urinary tract infection (UTI) will not cause CKD unless it is not treated or occurs recurrently. p. 1076
The nurse is caring for a patient undergoing peritoneal dialysis. What finding should the nurse report to the primary health care provider that would indicate peritonitis? Oliguria Hyperkalemia Hyponatremia Abdominal pain
Abdominal pain Rationale Peritonitis is caused by either a Staphylococcus aureus or a Staphylococcus epidermidis infection. It is manifested by abdominal pain, cloudy peritoneal effluent, and increased white blood cell count. Oliguria, hyperkalemia, and hyponatremia are complications associated with acute kidney injury. p. 1087
The patient admitted with sepsis is at risk of developing what renal pathology? Nephritis Glomerular nephritis Acute tubular necrosis Chronic kidney disease
Acute tubular necrosis Rationale Acute tubular necrosis is a result of an acute shock on the renal system and is recoverable, but the patient is likely to develop acute kidney impairment (AKI). Nephritis is an acute infection of the nephrons. Glomerular nephritis develops into chronic kidney disease and is not a result of sepsis. p. 1071
A dialysis nurse is performing hemodialysis for a patient with chronic kidney disease. Which action by the nurse will prevent blood clotting during the procedure? Addition of heparin to the blood Addition of dextrose to the blood Addition of icodextrin to the blood Addition of saline solution to the blood
Addition of heparin to the blood Rationale Heparin is added to the blood to prevent clotting when the patient's blood contacts a foreign substance. Dextrose and icodextrin are used as osmotic agents during dialysis. Saline solution is used to flush the dialyzer. p. 1089
The nurse is planning an education program on chronic kidney disease. Which ethnic group would the nurse target for promoting this event? Hispanics Asian descent Caucasian males African Americans
African Americans Rationale African Americans are at the greatest risk for developing kidney disease. Those of Asian descent, Caucasian males, and Hispanics are not at as great a risk.
Which substance can pass through the peritoneal membrane? Glucose Creatinine Fatty acids Amino acids
Amino acids Rationale Peritoneal membranes allow the passage of amino acids, polypeptides, and plasma proteins. Glucose, creatinine, and fatty acids cannot permeate the peritoneal membrane. p. 1086
The nurse recognizes that which medication is appropriate to give to patients with kidney failure? Magnesium antacids Aluminum preparations Angiotensin receptor blockers Nonsteroidal antiinflammatory agents
Angiotensin receptor blockers Rationale Hypertension is a common finding in a patient with kidney failure due to retention of sodium and water. This is treated with angiotensin receptor blockers. Magnesium antacids may aggravate hypermagnesemia in patients with kidney failure. Aluminum preparations should be used with caution in patients with chronic kidney disease because they are associated with bone diseases, such as osteomalacia. Nonsteroidal antiinflammatory agents are nephrotoxic and should not be administered to patients with renal failure because they can cause acute kidney injury. p. 1081
The patient has had type 1 diabetes mellitus for 25 years and now is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse finds that the patient has newly developed hypertension and difficulty with blood glucose control. The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? Serum creatinine Serum potassium Microalbuminuria Calculated glomerular filtration rate (GFR)
Calculated glomerular filtration rate (GFR) Rationale The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for three months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample, and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD. p. 1079
A patient with chronic kidney disease has an arteriovenous (AV) graft in the right forearm. What is the nurse's priority in determining the patency of the graft? Determine the range of motion of the right arm and shoulder Observe for clubbing of the fingers on the right hand of the AV graft site Compare radial pulses by checking the right and left pulses simultaneously Check for a bruit by listening over the right arm AV graft site with a stethoscope
Check for a bruit by listening over the right arm AV graft site with a stethoscope Rationale The arteriovenous (AV) graft is an artificial connection between an artery and vein to provide access for hemodialysis. Thrombosis may occur; therefore the need to determine patency is an essential assessment. Palpation of the site should indicate a thrill, which also indicates that the graft is patent. Listening over the AV graft should reveal a bruit sound, indicating patency. A bruit sounds similar to the impulse beat heard when measuring blood pressure. The arm that has the AV graft site should not be put through range-of-motion movements or exercises. Clubbing is not a complication observed in the fingers of a patient with an AV graft. Comparing the left radial pulse with the pulse on the AV graft site is not an accurate patency assessment procedure. p. 1087
When assessing the mental status of a patient in acute renal failure, the nurse recognizes that abnormal findings are most likely caused by what? Anger related to denial of chronic illness Delirium related to hypoxia of brain cells Confusion related to an increased urea level Aggression related to possible underlying comorbidities
Confusion related to an increased urea level Rationale In renal disease, urea is not filtered out of the blood by the kidneys and therefore accumulates in the blood. This results in toxicity to brain tissue, causing confusion. Anger is a possible emotional reaction, but it does not manifest as a change of mental status. Delirium related to hypoxia of brain cells is not a complication seen with acute renal failure. Aggression is not necessarily related to acute renal failure. pp. 1076, 1078
The nurse is teaching a patient with acute kidney injury about lifestyle modifications. Which actions by the patient indicate effective teaching? Consuming less salt Eating foods rich in protein Increase intake of fluids Consuming potassium-rich foods
Consuming less salt Rationale Sodium causes fluid and water retention and thereby increases blood volume; thus, the patient should consume less salt. Patients with renal impairment should decrease protein intake because proteins break down into urea, which is dangerous if it accumulates in the brain. Increasing the intake of fluid will increase the volume of fluid in the body. Because the kidney function is impaired, excess fluid cannot be eliminated and it accumulates in the body, leading to edema and congestive cardiac failure. Kidney disease is associated with hyperkalemia; thus eating potassium-rich food will worsen the condition and may lead to cardiac arrhythmia. p. 1074
The nurse reviews lab tests that have been prescribed for a patient in acute renal failure. Which is the best indicator of renal function? Potassium Creatinine BUN (blood urea nitrogen) ALT (alanine aminotransferase)
Creatinine Rationale Creatinine is the best indicator of renal function. Creatinine is a waste product of the skeletal muscles and is excreted through the kidneys. In renal failure, the kidneys are unable to excrete creatinine, leading to a serum level greater than the normal range of 0.2 to 1.0 mL/dL. Potassium excretion and regulation are impaired in acute renal failure, and potassium may therefore be increased. However, potassium may be increased for reasons other than renal disease, whereas increased creatinine is specific to renal disease. Blood urea nitrogen (BUN) is also used to measure kidney function, but other disorders such as dehydration may cause an increase in BUN. Alanine aminotransferase (ALT) is related to liver dysfunction, not renal dysfunction. p. 1072
During hemodialysis, the patient develops light-headedness and nausea. What is the priority action by the nurse? Administer hypertonic saline Administer a blood transfusion Decrease the rate of fluid removal Administer antiemetic medications
Decrease the rate of fluid removal Rationale The patient is experiencing hypotension from a rapid removal of vascular volume. The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. Hypertonic saline is not used because of the high sodium load. A blood transfusion is not indicated. Antiemetic medications may help the nausea but would not help the hypovolemia. p. 1090
Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect? Decreased hematocrit and diuresis Decreased serum creatinine and weight loss Increased potassium level and improved appetite Decreased white blood cell count and diaphoresis
Decreased serum creatinine and weight loss Rationale One of the main purposes of hemodialysis is removal of creatinine, other waste products, and water. Fluid loss may be measured by weighing the patient before and after the dialysis treatment and also by measuring the serum creatinine. The other answer options are inaccurate and/or incomplete. Hemodialysis will decrease potassium. It may also increase hematocrit and improve appetite. Hemodialysis will not produce diuresis and has no direct effect on WBC count or diaphoresis. p. 1085
Which process involves movement of fluid and molecules across a semipermeable membrane from one compartment to another? Dialysis Osmosis Diffusion Ultrafiltration
Dialysis Rationale Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another. Substances move from the blood through a semipermeable membrane and into a dialysis solution in this process. Osmosis is the movement of fluid from an area of lesser concentration to an area of greater concentration of solutes. Diffusion is the movement of solutes from an area of greater concentration to an area of lesser concentration. Ultrafiltration occurs when there is a pressure gradient across the membrane. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1084
The nurse caring for a patient with heart failure notes the patient has decreased urine output of 200 mL/day. Which laboratory finding aids in the diagnosis of prerenal azotemia in this patient? Normal creatinine level Decreased sodium level Decreased potassium level Elevated blood urea nitrogen (BUN)
Elevated blood urea nitrogen (BUN) Rationale The patient with heart failure has a decreased circulating blood volume. This causes autoregulatory mechanisms to preserve blood flow to essential organs. Laboratory data for this patient will likely demonstrate an elevation in BUN, creatinine, and potassium. Prerenal azotemia results in a reduction in the excretion of sodium, increased sodium and water retention, and decreased urine output. p. 1069
A nurse planning care for a patient with acute renal failure recognizes that the interventions of highest priority are directly related to what? Ineffective coping Excess fluid volume Impaired gas exchange Imbalanced nutrition: less than body requirements
Excess fluid volume Rationale The issue of excess fluid volume is the primary problem of acute renal failure and the highest priority for the nurse in this situation. The major problem with acute renal failure is altered fluid and electrolytes, which, if not managed, can lead to permanent renal damage, cardiac complications, and death. The nursing diagnosis of ineffective coping is due to the acute severity of the illness. The nursing diagnosis of impaired gas exchange is related to excess fluid volume, such as in the development of pulmonary edema. The nursing diagnosis of imbalanced nutrition, less than body requirements, is due to a decrease in appetite as a result of the acute renal failure. p. 1074
The nurse is preparing a patient for peritoneal dialysis. What nursing action is appropriate at this time? Inducing vomiting in the patient Recording the patient's blood pressure Measuring patient's blood glucose levels Have the patient empty the bladder and bowel
Have the patient empty the bladder and bowel Rationale The nurse should ensure that the patient's bladder and bowels are empty before inserting a catheter to prevent an accidental puncture and mixing of the dialysate with bowel contents. Induction of vomiting is not predialysis care. The nurse does not need to record the patient's blood pressure and blood glucose levels immediately prior to peritoneal dialysis. p. 1085
What is an intrarenal cause of acute kidney injury? Renal artery thrombosis Neuromuscular disorders Benign prostatic hyperplasia Hemolytic blood transfusion reaction
Hemolytic blood transfusion reaction Rationale Hemolytic blood transfusion reaction is an intrarenal cause of acute kidney injury. Renal artery thrombosis is a prerenal cause of acute kidney injury. Neuromuscular disorders and benign prostatic hyperplasia are postrenal causes of acute kidney injury. p. 1070
The nurse identifies that if a patient with chronic kidney disease (CKD) consumes baked beans, sweet potatoes, canned mushrooms, and chocolates, the patient is at risk for what condition? Hyperkalemia Hypernatremia Hypermagnesemia Hyperphosphatemia
Hyperkalemia Rationale Baked beans, sweet potatoes, canned mushrooms, and chocolates are rich in potassium. Hyperkalemia, or an abnormally high potassium level, is observed in patients with chronic kidney disease (CKD) with consumption of these foods. Hypernatremia occurs due to retention of sodium, aggravated by sodium-rich foods such as pickles. Hypermagnesemia, an increase in serum magnesium levels, is an electrolyte disturbance seen in the patients with CKD aggravated by intake of milk of magnesia and magnesium-containing laxatives. Hyperphosphatemia is aggravated by consumption of meat and dairy products in patients with CKD.
The nurse identifies that a patient with chronic kidney disease is at risk for which electrolyte disturbance? Hypokalemia Hyponatremia Hypercalcemia Hyperphosphatemia
Hyperphosphatemia Rationale A patient with chronic kidney disease (CKD) has hyperphosphatemia due to a decrease in elimination of phosphate by the kidneys. Hyperkalemia, rather than hypokalemia, is a serious electrolyte disturbance that occurs in the patient with CKD. Hypernatremia, rather than hyponatremia, leads to hypertension and fluid retention in a patient with CKD. Hypocalcemia, not hypercalcemia, occurs in the later stages of CKD due to the inability to absorb calcium in the absence of active vitamin D. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. pp. 1078-1079
The nurse suspects that which electrolyte abnormality is the cause of edema in a patient with chronic kidney disease? Hyperkalemia Hyponatremia Hypermagnesemia Hyperphosphatemia
Hyponatremia Rationale Hyponatremia is a decrease in serum sodium levels. Improper functioning of the kidneys impairs sodium excretion, which leads to sodium and water retention resulting in edema. Hyperkalemia can cause cardiac dysrhythmias. Hypermagnesemia may lead to absence of reflexes, decreased mental status, and hypotension. Hyperphosphatemia decreases serum calcium levels and reduces the kidney's ability to activate vitamin D. p. 1077
When obtaining a health history for the patient with chronic kidney disease, the nurse notes the following medications on the patient's medication list. The patient will need further education on which medication? Ibuprofen Calcium acetate Acetaminophen Calcium supplements
Ibuprofen Rationale Ibuprofen, and other nonsteroidal antiinflammatory drugs (NSAIDS), will cause further damage to the kidneys. Chronic kidney disease (CKD) patients should be taking Tylenol as prescribed for pain. CKD patients also could be consuming calcium supplements and PhosLo tablets as prescribed by the health care provider. p. 1083
Which is a manifestation of a mild form of acute kidney injury? Increased urine output Increased nitrogen level Increased potassium level Increased serum creatinine level
Increased serum creatinine level Rationale The mildest form of acute kidney injury is characterized by increased serum creatinine levels. Kidney injury is associated with decreased urine output, not increased urine output. Increased levels of potassium and nitrogen are characteristics of a severe form of acute kidney injury. p. 1072
A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? Hypokalemia Hyponatremia Large urine output Leukocytosis with cloudy urine output
Large urine output Rationale Patients frequently experience diuresis (a large volume of urine output) in the hours and days immediately following a kidney transplant. Hypokalemia, hyponatremia, and signs of infection are unexpected findings that warrant prompt intervention.
The nurse is caring for a patient who had a surgery for an arteriovenous fistula (AVF) in preparation for hemodialysis. What precautionary step should the nurse follow when caring for this patient? Initiate hemodialysis after four weeks. Never take blood pressure measurements in the extremity. Perform venipuncture in the extremity only after three months. Allow insertion of IV lines in the extremity only after six months.
Never take blood pressure measurements in the extremity. Rationale The nurse should inform the patient to never take blood pressure measurements, insert IV lines, or perform venipuncture in the extremity with vascular access. These special precautions are taken to prevent infection and clotting of the vascular access site. Maturation may take six weeks to months. Arteriovenous fistula (AVF) should be placed at least three months before initiating hemodialysis. p. 1088
A patient is scheduled to undergo peritoneal dialysis. What is the highest-priority action that the nurse should perform before starting dialysis? Obtain the patient's weight Administer pain medication to the patient Place the patient in a high Fowler's position Place the patient in the Trendelenburg position
Obtain the patient's weight Rationale The nurse must check the patient's weight before and after peritoneal dialysis (PD) to determine how much fluid has been removed. The patient should assume a position of comfort, such as a low Fowler's, unless there is difficulty with removing the effluent, in which case the nurse will position the patient to facilitate drainage. Administering pain medication is not a priority in regard to PD. There is no indication that the patient is experiencing pain. Placing the patient in a high Fowler's or Trendelenburg position is not recommended for patients during PD. p. 1089
The nurse preparing to administer a dose of calcium acetate to a patient with chronic kidney disease (CKD) should know that this medication should have a beneficial effect on which laboratory value? Sodium Potassium Magnesium Phosphorus
Phosphorus Rationale Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. Calcium acetate will not have an effect on sodium, potassium, or magnesium levels. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process. p. 1081
Which nursing intervention is appropriate for a patient during the oliguric phase of an acute kidney injury (AKI)? Provide spicy food Provide mouth care Provide plenty of fluids Provide ibuprofen as needed for pain
Provide mouth care Rationale Patients with acute kidney injury experience mucous membrane irritation caused by the production of ammonia in the saliva. Therefore the nurse should provide frequent oral care to prevent stomatitis. Spicy food should be avoided because it may aggravate the oral irritation. During the oliguric phase of AKI, the patient is typically volume overloaded because of impaired renal function and decreased urine output, therefore fluid intake should be limited. Ibuprofen, a nonsteroidal antiinflammatory drug, is nephrotoxic and may worsen the kidney injury.
A patient is being administered 15 g sodium polystyrene sulfonate orally for hyperkalemia. Which intervention should the nurse perform? Observe the patient for iron overload. Provide magnesium-containing antacids. Report peaked T waves in electrocardiogram (ECG). Inform the patient that constipation is an expected side effect.
Report peaked T waves in electrocardiogram (ECG). Rationale The nurse should report changes to the health care provider in the ECG, such as peaked T waves and widened QRS complexes; dialysis may be required to remove excess potassium. Monitoring for iron overload is a consideration for blood transfusions, but not for administration of sodium polystyrene sulfonate. The nurse should warn the patient that this treatment will often cause diarrhea because the preparation contains sorbitol, a sugar alcohol that has an osmotic laxative action. Magnesium-containing antacids should not be prescribed for patients with chronic kidney disease because magnesium is excreted by the kidneys. pp. 1080-1081
A patient had the surgical creation of an arteriovenous graft for the administration of hemodialysis. For what complication should the dialysis nurse monitor during hemodialysis? Hernia Bronchitis Pneumonia Steal syndrome
Steal syndrome Rationale The creation of arteriovenous access for hemodialysis causes arterial blood to shift to other areas, which can lead to vascular insufficiency. This condition is called steal syndrome. Hernias occur due to increased abdominal pressure caused by dialysate infusion. Patients undergoing peritoneal dialysis may develop bronchitis and pneumonia due to decreased lung expansion caused by repeated upward displacement of the diaphragm. p. 1088
